How often do you typically provide information to parents about the following items at discharge?					Is there an area in your written discharge instructions template specifically designated for you to provide information about the following items (i.e. not an area for general/additional instructions) ?
	Never	Sometimes	About Half the Time	Often	Always	No	Yes
Reason(s) patient was admitted to the hospital.	1	2	3	4	5	No	Yes
Names of medication(s) to be taken at home.	1	2	3	4	5	No	Yes
Purpose of medication(s) to be taken at home.	1	2	3	4	5	No	Yes
Dose of medication(s) to be taken at home.	1	2	3	4	5	No	Yes
Number of times per day (frequency) to take each medication(s) at home.	1	2	3	4	5	No	Yes
Duration (course) of treatment for medication(s) to be taken at home.	1	2	3	4	5	No	Yes
Name(s) or specialty of doctor(s) patient should see after discharge.	1	2	3	4	5	No	Yes
Appointment date(s) and time(s) for doctor(s) patient should see after hospital discharge.	1	2	3	4	5	No	Yes
Reason patient needs to see doctor(s) after hospital discharge.	1	2	3	4	5	No	Yes
Sign(s) or symptom(s) that should cause them to seek medical attention.	1	2	3	4	5	No	Yes
Action to take if specific sign(s) or symptom(s) is present (i.e., go the emergency department, call a specific doctor).	1	2	3	4	5	No	Yes
What child is allowed to eat and drink at home (if different than admission diet).	1	2	3	4	5	No	Yes
How active child can be (if different than admission activity level).	1	2	3	4	5	No	Yes
How child is allowed to bathe or shower (if different than bathing on admission).	1	2	3	4	5	No	Yes
When child is allowed to return to school.	1	2	3	4	5	No	Yes